The economic implications of HLA matching in cadaveric renal transplantation

Background The potential economic effects of the allocation of cadaveric ki dneys on the basis of tissue-matching criteria are controversial. We analyz ed the economic costs associated with the transplantation of cadaveric kidn eys with various numbers of HLA mismatches and examined the potential econo mic benefits of a local, as compared with a national, system designed to mi nimize HLA mismatches between donor and recipient in first cadaveric renal transplantations. Methods All data were supplied by the U.S. Renal Data System. Data on all p ayments made by Medicare from 1991 through 1997 for the care of recipients of a first cadaveric renal transplant were analyzed according to the number of HLA-A, B, and DR mismatches between donor and recipient and the duratio n of cold ischemia before transplantation. Results Average Medicare payments for renal-transplant recipients in the th ree years after transplantation increased from $60,436 per patient for full y HLA-matched kidneys (those with no HLA-A, B, or DR mismatches) to $80,807 for kidneys with six HLA mismatches between donor and recipient, a differe nce of 34 percent (P<0.001). By three years after transplantation, the aver age Medicare payments were $64,119 for transplantations of kidneys with les s than 12 hours of cold-ischemia time and $74,997 for those with more than 36 hours (P<0.001). In simulations, the assignment of cadaveric kidneys to recipients by a method that minimized HLA mismatching within a local geogra phic area (i.e., within one of the approximately 50 organ-procurement organ izations, which cover widely varying geographic areas) produced the largest cost savings ($4,290 per patient over a period of three years) and the lar gest improvements in the graft-survival rate (2.3 percent) when the potenti al costs of longer cold-ischemia time were considered. Conclusions Transplantation of better-matched cadaveric kidneys could have substantial economic advantages. In our simulations, HLA-based allocation o f kidneys at the local level produced the largest estimated cost savings, w hen the duration of cold ischemia was taken into account. No additional sav ings were estimated to result from a national allocation program, because t he additional costs of longer cold-ischemia time were greater than the adva ntages of optimizing HLA matching. (N Engl J Med 1999;341:1440-6.) (C)1999, Massachusetts Medical Society.